A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Limited hip abduction

Equal leg length

Symmetric gluteal and thigh skin folds

Femoral head remains in the acetabulum during the Barlow maneuver

Answer and Explanation

The Correct Answer is A

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

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Correct Answer is C

Explanation

Rationale:

A. Take mineral oil at bedtime: Mineral oil is not recommended for long-term use because it can interfere with absorption of fat-soluble vitamins and may lead to aspiration pneumonia, especially in older adults. Safer stool softeners or laxatives should be used for opioid-induced constipation.

B. Decrease insoluble fiber intake: Insoluble fiber, such as wheat bran, helps bulk the stool and promote bowel movements. Reducing fiber intake can worsen constipation rather than relieve it, especially in clients taking opioids.

C. Increase exercise activity: Regular physical activity stimulates peristalsis and helps prevent constipation. Movement is a key non-pharmacologic strategy to counteract the slowed gastrointestinal motility caused by opioids.

D. Drink 1.5 L of fluids each day: Although hydration is important, adults typically require around 2 to 3 liters of fluid daily unless contraindicated. Limiting intake to 1.5 L may be insufficient to support normal bowel function and soften stool.

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy. B. Suggest the client join a support group for people who have colostomies. C. Instruct the client's partner to assume care of the colostomy for the client. D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.

Correct Answer is B

Explanation

Rationale:

A. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing negative emotions can hinder psychological adjustment. Clients should be encouraged to express their feelings openly as part of the adaptation and coping process.

B. Suggest the client join a support group for people who have colostomies: Support groups can provide emotional reassurance, shared experiences, and practical coping strategies. Seeing others manage their stomas successfully can promote acceptance and self-confidence.

C. Instruct the client's partner to assume care of the colostomy for the client: While partner support is important, encouraging dependence may delay the client’s adjustment and self-care ability. The goal should be to promote independence and acceptance at the client’s pace.

D. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: A transfer is not necessary unless the client has complex needs. Initial support, education, and emotional guidance should be provided in the current care setting.

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A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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